Provider Demographics
NPI:1053048702
Name:MARTINEZ, CAROL ANN
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 W CHICAGO BLVD STE 13
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-1666
Mailing Address - Country:US
Mailing Address - Phone:517-423-0004
Mailing Address - Fax:517-423-0010
Practice Address - Street 1:808 W CHICAGO BLVD STE 13
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-1666
Practice Address - Country:US
Practice Address - Phone:517-423-0004
Practice Address - Fax:517-423-0010
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703078042164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse